A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take?
Sit at or below the client's eye level during feedings.
Instruct the client to lift her chin when swallowing.
Talk with the client during her feeding.
Discourage the client from coughing during feedings.
The Correct Answer is A
Rationale:
A. Sit at or below the client's eye level during feedings: Positioning the nurse at or slightly below the client’s eye level promotes effective communication and allows close observation of swallowing. It helps the nurse monitor for signs of aspiration, coughing, or choking, which is critical in clients with dysphagia to ensure safety during meals.
B. Instruct the client to lift her chin when swallowing: Clients with dysphagia should be taught to tuck the chin slightly toward the chest, not lift it, to protect the airway and facilitate safer swallowing. Lifting the chin increases the risk of aspiration and airway compromise.
C. Talk with the client during her feeding: Talking while swallowing increases the risk of aspiration because it distracts the client and can disrupt coordinated swallowing. Silence and focused attention are recommended during feeding to ensure safe intake of food and liquids.
D. Discourage the client from coughing during feedings: Coughing is a protective reflex that clears the airway if food or liquid enters the trachea. Discouraging it could increase the risk of aspiration and choking, making it unsafe to suppress this natural defense mechanism.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","F"]
Explanation
Rationale:
A. "I will avoid all alcohol while taking this medication.": Alcohol can increase the risk of bleeding while a client is on anticoagulants by affecting platelet function and liver metabolism of the drug. Avoiding alcohol reduces the likelihood of complications such as gastrointestinal bleeding or excessive bruising, making this an appropriate and effective understanding of anticoagulant safety.
B. "I will ask my provider before taking any supplements.": Many herbal supplements and over-the-counter medications can interact with anticoagulants, either increasing or decreasing their effect. Consulting the provider ensures the client avoids dangerous interactions that could lead to bleeding or clotting complications.
C. "I will call my provider if I have blood in my urine.": Hematuria may indicate significant bleeding while on anticoagulant therapy. Promptly reporting this symptom allows early intervention and prevents serious complications such as anemia or renal damage, showing that the client understands the need to monitor for adverse effects.
D. "I will plan to eat a green salad every day.": While leafy green vegetables are healthy, they are high in vitamin K, which can interfere with certain anticoagulants like warfarin. Regular high intake without provider guidance could reduce the medication’s effectiveness, so this statement reflects a misunderstanding rather than effective teaching.
E. "I will stop taking the anticoagulant if I get a nosebleed.": Stopping anticoagulants without provider instruction can increase the risk of thromboembolism. Minor bleeding like a nosebleed should be reported, not managed by abruptly discontinuing the medication, so this reflects unsafe practice.
F. "I will be careful to not cut myself.": Minimizing trauma and preventing cuts or injuries is essential while on anticoagulants because even minor injuries can lead to significant bleeding. This shows the client understands the practical precautions needed to stay safe during therapy.
Correct Answer is D
Explanation
Rationale:
A. "Why did this happen to me?": This statement reflects the anger stage of grief, where the client questions fairness and expresses frustration about their situation. It does not involve negotiating or making promises in exchange for a desired outcome.
B. "I never did anything bad to hurt anyone": This reflects the guilt or depression stage, as the client may be feeling remorse or self-blame related to their illness. It is an emotional expression rather than an attempt to bargain.
C. "I hope my family can accept what's happening": This reflects the acceptance stage, where the client begins to come to terms with their prognosis and focuses on reconciliation or emotional resolution.
D. "If I get better I will study to become a priest.": This is an example of the bargaining stage, where the client attempts to negotiate or make promises in exchange for a desired outcome, such as improved health or extended life. It demonstrates the “what if” reasoning characteristic of this stage of grief.
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